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P0685 Hwy 601Si,�rtt 1 +!, ti x^ " a.y` r- ;iY', p ;.a � % T 4' . � - ' - r 3 Y x� , f;;-' •• t'i.., i'�— .7 a'. AUTHORIZATION NO: 0785 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Pe mittee's -P.O. Box Box 848 Name; �l til '.�.� �; l Mocksville, NC 27028 Subdivision Name: / Phone #: 704-634-8760 Directions to property: t�� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# f SYSTEM CONSTRUCTION Road Name: �! Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any. Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Articlel l of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) j , J ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION r•<�.I.l �,� "� ' `�`f IS VALID FOR A PERIOD OF FIVE YEARS. _ ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED W4G DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Naipe: `" ,IJ,ci, f _ Subdivision Name: IV Directions to property: (E? f Section: Lot: - IMPROVEMENTPERMIT Tax Office PIN:#f Road Name: It, s Zip: - j% e.!A y , **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must beobtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TIIE SYSTEM CONTRACTORN EMUS E E LANGGETIESPYOURWASTEWATER A TEW TER ORE ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE,,!_!V/V- # BEDROOMS f # BATHS —V—# OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE - # PEOPLE/SHIFT / # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE '� (- TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) ` NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. ` PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH L LINEAR Fr. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE #IS (704) 634-8760. OPERATION PERMIT ,�, 9 A A SYSTEM INSTALLED BY: �A1�1�`7 /VUl.La3�� Q ►J��S s (l AUTHORIZATION NO. v ' v OPERATION PERMIT BY: '`�`�'DATE: �o "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05196 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE • Davie County Health Department Environmental Health Section D P.O. Box 848 APR — 3 1997 Mocksville, NC 27028 W (704)634-8760 . ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be BilledA u ��iv; c� / Contact Person Mailing Address /�y�� l E/1 iTDw 1Q a Home Phone City/State/Zip _0 / 1 D C,� t),. IJe C. 07 %�c;t e Business Phone 2. Name on Permit/ATC if Different/than Above Mailing Address -LD,:)-,')L _� e,1 /�u v N leJ- City/State/Zip ,i �,ll% ��/Ji %/� Gi L • % 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC (/]Both 4. System to Serve: [ ] House Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms-_ # Bathrooms_; [ ] Dishwasher [ ] Garbage Disposal k,I-Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [✓ County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes VJ-No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXEWUOF THE PROPERTY MUST BE M SUBMITTED WITH Trocksvflle) APPLICATION. Property Dimensions: 3/,l R cY p WRITE DIRECTIONS (from TO PROPERTY: Tax Office PIN: 5V - /.2, -`9/<0 ; Cn b 1 Property Address: Road Name 0 1 City/zip rk4 t,; Ile If • C' If in Subdivision provide information, as follows: Name: Section: Lot#: S /1 d— This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Dame County INIth Department to enter upon above described property located in Davie County and owned by. Revised DCHD (06-96) all testing procedures as necessary to determine the site suitability. THIS AREA MAY $E USED FOR DRAWINQ YOUR SITE PLAN: E S 05059'301 W 252.40' new ew line v 120.44' v u 0 0 �n n n u r O IN a fl) 00 Z n N 00 n C) p OD CA u J I N 00 0n W N W W °u O W n _ 6 O n O Parcel 29 Parcel 35.16 Sohn A. S c t'arcel 29 m D.B. 142 Pillman etal 364, 5th R/W as claimed b tract a JOhn A. S rc81 35.17 Y the�9hway Commission `^ D.@, 142 Pi11rnon eta, o — 364, 2nd 0 U.S. 601 0 n a. D.B. 163-440 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME a<Ji9y lr° / DATE EVALUATED PROPOSED FACILITY /YI PROPERTY SIZE SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit ROAD NAME lo�� Public C� Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH y(9 f Texture group Consistence r - Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ` > EVALUATION BY: �r�Y LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: DCHD (O1-90) IADl"-&`11 •, Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable I FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 ■ ■ ■■ ■■E■ ■■M■ ■O■■ ■E■■ ■■m■ ■ ■ MEMO ■E■■ ■■■■ ■■■■ ■■EMM■ ■M■■E■ ■E■N■■ ■■E■■M■ ■■MEMS■ ■■NEE■■ ■MENN■■ ■EMEME■ ■■MMM■ME■ ■N■ENOM■■ ■E■E■■MO■ ■E■OMON■■ MEMEMEMEN ■■N■M■NE■ MEMEMMEMM ■EM■■MM■■ ■■■■M■■E■ ■■■ME■■M■ ■■M■M■ME■ MEMEMEMEM ■E■■MME■■ ■■MME■■E■ mommommom MEMENMENO ■M■EMM■■■ ■■MMM■MM■ MEMEMEMEM ■E■M■■E■■ ■■■E■■EM■■ ■■M■■EMO■■ ■■M■MME■E■ MEMMEMEMEM ■■■■M■■EM■ MEMMEMMEME ■■EM■■E■■■ ■■■NOME■E■ EMENMEMEME ■M■■M■■EM■ ■■■M■■EMM■ ■■■MEMM■■■ MUMMEMMEME ■M■■ME■■E■ ■E■■N■■EM■ ■E■■M■■E■■ ■■E■■M■ ■O■■EM■ ■M■■ME■ ■■EEME■ ■MEM■U ■NEEM ■■■■■E■ ■■■■M■■ ■■■■E■■ MEMO■■■ ■■■n■■■ ■■M■■■■ M■■EM■■ w■■m■■■ ■■E■■E■ ■M■MME■ ■MEMME■ ■■M■■N■ ■■ME■■■ ■MM■■M■ ■E■■ME■ ■M■MME■ ■E■■M■■ ■MEMME■ ■M■■ME■ ■E■■■■■ ■■■ME■■ ■■MM■■■ ■■EMO■■ ■M■■ME■ ■■N■ ■EM■ ■EM■ NONE MEMO ■E■■ moos ■■M■ ■■ ■E■■ME■■■ ■E■OM■■E■ ■■NO■■■E■ ■■M■■MEE■ ■E■EMEM■■ ■EMMEM■■■ ■E■M■■M■■ ■OM■■MME■ ■E■■MEM■■ ■EMME■■■■ ■ ■ ■ ■■■■ ■O■■ mono ■mm■ ■E■■ ■O■■ ■EE■ ■■M■ mono ■E■■ ■OE■ ■EE■ ■■E■ ■E■■ ■E■■